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Domperidone
A prescription drug that can help
women increase their milk supplies
Introduction
Domperidone (Motilium)
is a drug that has, as a side effect, stimulating or increasing milk
production, probably by increasing prolactin
production by the pituitary gland. Prolactin
is the
hormone that stimulates the cells in the mother's breast to produce
milk. Domperidone increases prolactin
secretion indirectly, by interfering with the action of dopamine whose
action
is to decrease the secretion of prolactin
by the
pituitary gland. Domperidone is generally
used for
disorders of the gastrointestinal tract (gut) and has not been released
in
Canada for use as a stimulant for milk production. This does not mean
that it
cannot be prescribed for this reason, but rather that the manufacturer
does not
back its use for increasing milk production. However, there are several
studies
that show that it works to increase milk production and that it is
safe. It has
been used, for several years, in small infants who spit up and lose
weight, but
was replaced until a few years ago by cisapride
(Prepulsid) (cisapride
has since
been taken off the market because it can cause serious cardiac
problems). Domperidone is not in the same
family of medication as cisapride and has
never had the cardiac side effects that cisapride
does. Another, related, but older medication, metoclopramide
(Maxeran), is
also known to increase milk production, but it has frequent side
effects which
have made its use for many nursing mothers unacceptable (fatigue,
irritability,
depression). Domperidone has many fewer
side effects
because it does not enter the brain tissue in significant amounts (does
not
pass the blood-brain barrier).
When is it appropriate to use domperidone?
Domperidone must
never
be used as
the first approach to correcting breastfeeding difficulties. Domperidone is not a cure for all things. It
must not be
used unless all other factors which may result in insufficient milk
supply have
been dealt with first. (See Handout: Protocol to Increase Intake of Breastmilk by the Baby). These other factors
include:
Correcting the baby's latch so that the baby
can
obtain as
efficiently as possible the milk which the mother has available.
Correcting the
latch may be all that is necessary to change a situation of "not enough
milk" to one of "plenty of milk".
Using breast compression to increase the
intake of
milk
(Handout #15: Breast Compression).
Using milk expression
after
feedings to
increase the supply.
Correcting sucking problems, stopping the use
of
artificial
nipples (handout #5: Using a Lactation Aid, and #8: Finger Feeding) and
other
stratagems.
Using Domperidone
for
Increasing
Milk Production
Domperidone works
particularly
well to increase milk production under the following circumstances:
It has frequently been noted that a mother
who is
pumping
milk for a sick or premature baby in hospital has a decrease in the
amount she
pumps around 4 or 5 weeks after the baby is born. The reasons for this
decrease
are likely many, but domperidone generally
brings the
amount of milk pumped back to where it was or even to higher levels.
When a mother has a decrease in milk supply,
often
associated with the use of birth control pills (avoid strogen
containing birth control pills while breastfeeding), or on occasion,
for no
obvious reason when the baby is 3 or 4 months old, domperidone
will often bring the supply back to normal.
Domperidone still
works, but often
less dramatically when:
The mother is pumping for a sick or premature
baby
but has
not managed to develop a full milk supply.
The mother is trying to develop a full milk
supply
while
nursing an adopted baby.
The mother is trying to wean the baby from
supplements.
Side Effects of Domperidone
As with all medications, side effects are
possible, and many
have been reported with domperidone
(textbooks often
list any side effect ever reported, but symptoms reported are not
necessarily
due to the drug a person is taking). There is no such thing as a 100%
safe
drug. However, our clinical experience has been that side effects in
the mother
are extremely uncommon, except for increasing milk supply. Some side
effects
which mothers we have treated have reported (very uncommonly,
incidentally):
Headache which disappeared when the dose was
reduced
(probably the most common side effect)
Abdominal cramps
Dry mouth
The amount that gets into the milk is so tiny
that
side
effects in the baby should not be expected. Mothers have not reported
any to
us, in many years of use. Certainly the amount the baby gets through
the milk
is a tiny percentage of what babies would get if being treated for
spitting up.
Are there long term concerns about the use of
domperidone?
The manufacturer states in its literature
that
chronic
treatment with domperidone in rodents has
resulted in
increased numbers of breast tumours in the
rodents.
The literature goes on to state that this has never been documented in
humans.
Note that toxicity studies of medication usually require treatment with
huge
doses over periods of time involving most or all of the animal's
lifetime. Note
also that not breastfeeding increases the risk of breast cancer, and
breast
cancer risk decreases the longer you breastfeed.
Using Domperidone
Generally, we start domperidone
at
20 milligrammes (two 10 mg tablets) four
times a day.
If taking domperidone 4 times a day is
inconvenient,
30 milligrammes (three 10 mg tablets)
three times a
day is fine. Printouts from the pharmacy often suggest taking domperidone 30 minutes before eating, but that
is because
of its use for digestive intolerance. You can take the domperidone
about every 6 hours, when it is convenient (there is no need
to wake up to keep to a 6 hour schedule-it does not make any difference).
Most mothers take the domperidone for 3 to
8 weeks.
Mothers who are nursing adopted babies may have to take the drug much
longer.
After starting domperidone,
it may
take three or four days before you notice any effect, though sometimes
mothers
notice an effect within 24 hours. It appears to take two to three weeks
to get
a maximum effect, but some mothers have noted effects only after 4 or
more
weeks. It is reasonable to give domperidone
a trial
of at least 4 weeks before saying it doesn't work.
How Long Can I Use domperidone?
When domperidone
was
being used
for babies (and now that cisapride is off
the market,
it is being used again), it was common for the babies to be on the
medication
for several months. Since the amount of domperidone
that gets into the milk is very small indeed, from the baby's point of
view,
there should be no issue in the mother taking it to increase milk
supply for
several months. Our experience with this drug is that short-term side
effects
are very few and almost always very mild. Worldwide experience with domperidone over at least 2 decades suggests
that long-term
side effects also are rare. Some of the mothers in our clinic,
breastfeeding
adopted babies, have been on the medication for 18 months without any
apparent
side effects.
How Long Does it Take for Domperidone
to Work?
It depends on the situation. In a situation
where
the mother
had had a good milk supply, but it decreased for some reason (e.g.
going on the
birth control pill), domperidone often
works very
rapidly to increase the milk supply. Often, within a day or two, the
mother is
seeing a difference (and so does her baby). But this is not always so,
and in
any situation, it may take a week or more for the mother to get an
effect. On
occasion, we have had mothers only starting to get an increase in their
milk
supplies a month or more after starting to take it. Therefore, we
generally
recommended that the mother take the domperidone
for
at least 6 weeks in order to be sure whether it has worked or not.
It is our impression that domperidone
works best after the first few weeks after the mother has given birth.
This has
not been proved, but there are theoretical reasons why it may be so.
For this
reason, we have often waited to prescribe it until the baby is at least
3
weeks, mainly because we did not want the mother to become discouraged
if she
did not see any rapid increase in her milk supply.
How Do I Know How Long to Take Domperidone?
Usually, we ask the mother take it for two
weeks
and
re-evaluate. There are several possibilities.
The milk supply has increased substantially,
to
the point
where there is no longer a consideration of using supplements, or the
mother
has been able to stop supplements with the baby continuing to gain well
on
breastfeeding alone.
The milk supply has increased to a point that
the
mother
feels is satisfactory. For example, she may still need to supplement,
but the
baby does not fuss any more at the breast and drinks contentedly.
In these two situations, we would ask the
mother
to start
weaning herself from the domperidone in
this way.
Most mothers are taking 2 tablets four times
a day, or 3 tablets three times a day. When
you are
ready to
start weaning from the domperidone, drop
one pill, so
that now, instead of 8 pills a day, you will be taking 7, or if you
were taking
9 pills a day, you will be taking 8.
Wait 4 or 5 days, a week if you wish. If you
see
no change
in your milk supply, drop another pill.
Wait another 4 or 5 days. If you see no
change in
your milk
supply, drop another pill.
Continue in this way until you are down to no
pills a day.
If there has been no decrease in your milk supply, or if there has been
a small
decrease that does not affect the breastfeeding and baby's weight gain,
that's
just what we hope to have happened, and many mothers manage this.
If, however, your supply diminishes
significantly,
return to
the previous effective dose and do not drop any pills for a couple of
weeks at
least.
If you are keen to go off the domperidone,
after a couple of weeks on the same dose, start dropping a pill a day,
as in
step 1 above. Some mothers, who were not able to get off the domperidone with steps 1-4 above, can
do it the second or the third time.
You may find that you have to continue a
certain
dose to
maintain your milk supply. But following steps 1-4 above will get you
to the
lowest effective dose.
It is possible, however, that after two weeks,
you are not where you want to be. In that case, you should continue
using the domperidone. If you are still
not where you want to be
after 6 weeks of domperidone, it is time
to think
some more about the domperidone. If you
are
supplementing, and have managed to reduce the amount of supplement from
14
ounces to 10 ounces, is it really worth taking a drug in order to do
this? If
you feel it is, then continue with the domperidone,
but try weaning the number of pills down to minimum number that
maintain your
milk supply, as above. If you do not feel it is worth it, try weaning
down as
above, and if you don't see any change once you get to no pills a day,
fine.
However, if you do notice a real change in the milk supply as you lower
the
dose, maybe the domperidone is more
effective than
you had thought (remember, after 6 weeks, your baby is significantly
heavier,
and it may be that instead of needing 14 ounces without domperidone,
the baby might actually need 20 ounces to maintain good weight gain, in
which
case the domperidone is actually doing
something).
Remember: Before using domperidone,
the breastfeeding should be fixed, and as quickly as possible. This
means:
Getting the best latch
possible.
This alone may result in the baby getting enough milk.
Using compression to
continue
milk intake
by the baby.
"Finish" one side before offering the other
(see
protocol for increasing breastmilk intake
by the baby
for an explanation on how to know the baby is getting milk)
Do not limit the baby to one side if the baby
is
not getting
enough. Switch to the other side once the baby is no longer getting
milk even
with the compression.
Switch back and forth, as long as the baby is
getting good
amounts of milk.
See the protocol for increasing breastmilk
intake by the baby.
Handouts #19a and #19b.
Domperidone.
January 2003
Written by Jack Newman,
MD,
FRCPC.
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